Diabetics on hemodialysis in El-Minia Governorate,Upper Egypt: five-year study

Introduction  

The number of patients with end-stage renal disease (ESRD) due to diabetic nephropathy (DN) is increasing worldwide. In many countries, diabetes mellitus has become the most frequent cause of ESRD. The goal of this work is to critically evaluate the prevalence of DN among chronic regular hemodialysis (HD) patients in El-Minia Governorate, to evaluate changes over the course of 5 years, and to compare data of El-Minia Governorate with data from the United States and other countries, in an attempt to detect factors that might explain causes of the differences.     

Changing pattern of end-stage renal disease in central and eastern Europe.

BACKGROUND: The epidemiology of end-stage renal disease (ESRD) is changing all over the world. Particularly dramatic changes of the epidemiology of ESRD have occurred in central and eastern Europe (CEE). The aim of the present study was (i) to document the further expansion of renal replacement therapy (RRT) noted in recent years in CEE and (ii) to analyse in some detail treatment modalities and underlying renal conditions. METHODS: Three independent surveys were performed in 1995, 1997 and 1998. Fifteen CEE countries participated. The data were mainly obtained from national registries which are based on centre and patient questionnaires. RESULTS: The data collected from 15 CEE countries document further expansion of RRT in this region. The report includes data on the availability of RRT in Byelorussia, Estonia, and Russia which have become available for the first time. The epidemiology of dialysed patients has changed remarkably. In the majority of countries the number of diabetic patients has increased, most dramatically so in the Czech Republic (31% of all dialysed patients), in the majority of the other countries 10-14%. The number of ESRD patients with the diagnosis of hypertensive nephropathy has also increased and this was accompanied by an increase in proportion of elderly (>65 years) patients, i.e. 46% in the Czech Republic and 12-25% in most other countries. CONCLUSION: Dramatic changes of the availability of RRT treatment have occurred in central and eastern Europe. The proportion of diabetic nephropathy and elderly patients has risen. Large differences in RRT exist between individual CEE countries and this appears mainly dependent on the level of economic development.     

The epidemiology of end-stage renal disease in Iran in an international perspective.

INTRODUCTION: The epidemiology of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is under continuous evolution all over the world. We report here the epidemiological analysis of ESRD and RRT in Iran and discuss it against the background of the international situation. METHODS: This epidemiological report is based on data from centre questionnaires which were collected in Iran from 1997 onwards, with a response rate of 100%. RESULTS: The prevalence/incidence of RRT patients were 238/49.9 p.m.p. in the year 2000. Haemodialysis and kidney transplantation were the most common RRT modalities, accounting for 53.7% and 45.5% of prevalent RRT patients, respectively. The proportion treated by peritoneal dialysis was very low (<1%). Home haemodialysis was not performed. The majority of haemodialysis centres used synthetic membranes (70%) and 100% of the sessions were performed using acetate as a buffer; 42.5% of haemodialysis patients were treated with a twice-weekly regimen, whilst 49.6% were on the standard thrice-weekly regimen. The majority of RRT patients in Iran were young to middle aged. The great majority of renal allografts came from living donors (mainly unrelated to recipients). The main renal diseases leading to ESRD were diabetes and hypertension. The third most common category was "cause unknown". CONCLUSION: The epidemiology of RRT in Iran is characterized by: (i) young patient age (younger than the international average); (ii) high proportion of patients receiving renal allograft; (iii) use of living-unrelated donors as the major source of renal allografts.     

Association Between Attributed Cause of End-Stage Renal Disease and Risk of Death in Brazilian Patients Receiving Renal Replacement Therapy

Background. Studies conducted in several countries have indicated that the survival of patients undergoing renal replacement therapy (RRT) depends on the attributed cause of end-stage renal disease (ESRD). Objectives. This study was conducted to evaluate the association between attributed cause of ESRD and mortality risk in RRT patients in Brazil. Methods. We analyzed 88,881 patients from the Brazilian Ministry of Health Registry who were undergoing RRT between April 1997 and July 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of death in patients with ESRD secondary to diabetes mellitus (DM), polycystic kidney disease (PKD), and primary glomerulopathies (GN) compared with a reference group comprised of patients with ESRD caused by hypertensive nephropathy. Patient's age, gender, and length of time (years) in RRT before inclusion in the registry (vintage) were included in the adjusted Cox model. Results. Compared with the reference group, the mortality risk was 27% lower in patients with PKD (RR = 0.73, 95% CI: 0.65–0.83, p< 0.0001); 29% lower in patients with GN (RR = 0.71, 95% CI: 0.68–0.74, p< 0.0001); and 100% greater in DM patients (RR = 2.00, 95% CI: 1.92–2.10, p< 0.0001). These relative risks remained statistically significant after adjustment for age, gender, and length of time in RRT before inclusion in the registry. Conclusions. Our data indicate that compared with the patients with hypertensive nephrosclerosis as attributed cause of ESRD, patients undergoing RRT in Brazil with idiopathic glomerulopathy and polycystic kidney disease have a lower risk of mortality, and patients with diabetes mellitus have a greater risk of mortality.     

Association between attributed cause of end-stage renal disease and risk of death in Brazilian patients receiving renal replacement therapy

BACKGROUND: Studies conducted in several countries have indicated that the survival of patients undergoing renal replacement therapy (RRT) depends on the attributed cause of end-stage renal disease (ESRD). OBJECTIVES: This study was conducted to evaluate the association between attributed cause of ESRD and mortality risk in RRT patients in Brazil. METHODS: We analyzed 88,881 patients from the Brazilian Ministry of Health Registry who were undergoing RRT between April 1997 and July 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of death in patients with ESRD secondary to diabetes mellitus (DM), polycystic kidney disease (PKD), and primary glomerulopathies (GN) compared with a reference group comprised of patients with ESRD caused by hypertensive nephropathy. Patient's age, gender, and length of time (years) in RRT before inclusion in the registry (vintage) were included in the adjusted Cox model. RESULTS: Compared with the reference group, the mortality risk was 27% lower in patients with PKD (RR=0.73, 95% CI: 0.65-0.83, p<0.0001); 29% lower in patients with GN (RR=0.71, 95% CI: 0.68-0.74, p<0.0001); and 100% greater in DM patients (RR=2.00, 95% CI: 1.92-2.10, p<0.0001). These relative risks remained statistically significant after adjustment for age, gender, and length of time in RRT before inclusion in the registry. CONCLUSIONS: Our data indicate that compared with the patients with hypertensive nephrosclerosis as attributed cause of ESRD, patients undergoing RRT in Brazil with idiopathic glomerulopathy and polycystic kidney disease have a lower risk of mortality, and patients with diabetes mellitus have a greater risk of mortality.     

Renal replacement therapy for diabetic end-stage renal disease: data from 10 registries in Europe (1991-2000)

BACKGROUND: There is concern about the rising prevalence of type 2 diabetes mellitus and of the resultant nephropathy. This study uses data from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry to provide information on the epidemiology and outcome of renal replacement therapy (RRT) for end-stage renal disease (ESRD) due to diabetic nephropathy (DN). METHODS: Data from the following 10 registries: Austria, French-speaking Belgium, Denmark, Finland, Greece, Norway, Scotland (UK), Catalonia (Spain), Sweden, and The Netherlands were combined. Average annual changes (%) were estimated by Poisson regression. Analyses of mortality were performed by Cox regression. RESULTS: An increase in patients with type 2 DN entering RRT has been observed (+11.9% annually, P < 0.05), while large differences in RRT incidence in this disease continue to exist between countries in Europe. There was a reduction in mortality during the first 2 years on dialysis therapy among patients with type 2 DN (AHR 0.96, 95%CI 0.94-0.97 annually). The mortality among transplant recipients decreased for both type 1 DN and nondiabetic ESRD (non DN) within the 1995-1998 cohort (type 1 DN: AHR 0.49, 95% CI 0.35-0.68; non DN: AHR 0.79, 95% CI 0.69-0.90) compared to the 1991-1994 cohort. CONCLUSION: This report has shown that during the last decade there has been a marked increase in the incidence of RRT for type 2 DN. Survival analysis showed that over the period 1991-1999 the mortality rates of all dialysis patients and of type 1 diabetic and nondiabetic renal transplant recipients have fallen.     

Combined assessment of cardiac systolic dysfunction and coronary atherosclerosis used to predict future cardiac deaths after starting hemodialysis

BACKGROUND/AIMS: Identification of end-stage renal disease (ESRD) patients at high risk for cardiac events is important for clinical dialysis management. The present study determined whether the combination of cardiac function and coronary atherosclerosis could predict future cardiac events after starting renal replacement therapy (RRT). METHODS: We prospectively assessed left ventricle ejection fraction (EF) and Gensini score (GS) using angiographic severity of coronary atherosclerosis in 88 consecutive ESRD patients [mean age 62 years; 69 males (78%); 55 patients (64%) with diabetic nephropathy] at the initiation of RRT. EF was analyzed by echocardiogram, and GS was scored by coronary angiography within 3 months after starting RRT. The study end point was cardiac death. For analysis of the association between cardiac death and EF and GS measures, the univariate and multivariate Cox proportional hazards model was used. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value, and accuracy of event-free prediction were evaluated. RESULTS: Twenty-four patients (27%) had low cardiac function (EF <50%; low EF) and 44 patients (50%) had severe coronary atherosclerosis (GS >15; high GS). During a follow-up period of 3 years, cardiac death occurred in 21 patients (24%). The PPV of low EF and high GS was 42 and 39%, respectively; the highest PPV (53%) was obtained when low EF and high GS were combined. The cumulative survival rate at 5 years in patients with both low EF and high GS was significantly lower than those with high EF and low GS (91 vs. 22%, p < 0.0005). CONCLUSION: The combined assessment of cardiac function and coronary atherosclerosis at the initiation of RRT strongly predicts future cardiac events.     

The epidemiology of end-stage renal disease in the Baltic countries: an evolving picture.

INTRODUCTION: The epidemiology of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is under continuous evolution all over the world. Of particular interest is the development of RRT in the countries of the former Soviet bloc which underwent great political and socio-economical changes in the last decade. We report here the epidemiological analysis of ESRD and RRT in the three Baltic countries: Lithuania, Estonia, Latvia. Subjects and methods. This epidemiological report is based on data from centre questionnaires which were collected from 1996 onwards, with a response rate of 98-99%. RESULTS: The prevalence/incidence of RRT patients in 1999 were 213/99.5 p.m.p. in Lithuania, 186/45.5 p.m.p. in Estonia and 172/55.8 p.m.p. in Latvia. Haemodialysis (HD) was the most common RRT modality in Lithuania (60% of prevalent patients), but not in Estonia (29%), while in Latvia it was nearly as common as renal transplantation (45 and 46%, respectively). Home HD was not performed. The proportion treated by peritoneal dialysis (PD) was very low in Lithuania (4% of RRT patients), while the percentage was higher in Latvia (9%) and Estonia (20.4%). The percentage of patients on RRT treated by renal transplantation was high throughout, representing the main modality of treatment in Estonia (50.5% of RRT prevalent patients, 94 p.m.p.) and in Latvia (46%, 79 p.m.p.) and being high in Lithuania (36%, 77 p.m.p.). The main renal diseases leading to ESRD were glomerulonephritis, pyelonephritis and diabetes. CONCLUSION: The epidemiology of RRT in the Baltic countries is undergoing rapid changes. Transplantation has reached an impressive level. A high percentage of RRT patients live with a functioning graft.     

Parathyroidectomy in patients on renal replacement therapy: an epidemiologic study

Secondary hyperparathyroidism is a frequent complication of long-term dialysis treatment, and despite recent advances in medical therapy, surgical parathyroidectomy (PTx) is necessary in a considerable number of uremic patients. A prevalence of PTx of 22% was reported in Europe in 1988 in patients on dialysis from 10 to 15 yr, but no large-scale epidemiologic study has been published since then. The aim of the study was to evaluate the prevalence, incidence, and risk factors for PTx in patients on renal replacement therapy (RRT) in Lombardy and to determine whether the incidence has changed over time. The study involved 14,180 patients included in the Lombardy Registry of Dialysis and Transplantation who received RRT for end-stage renal disease (ESRD) between 1983 and 1996. Cox-proportional hazards regression models were used to evaluate the risk factors of PTx, the explanatory covariates being age on admission to RRT, gender, underlying renal disease (nondiabetic or diabetic nephropathy), and dialysis modality (peritoneal dialysis or hemodialysis). The prevalence of PTx in the 7371 ERSD patients who were alive on December 31, 1996, was 5.5% and increased with the duration of RRT (9.2% after 10 to 15 yr, 20.8% after 16 to 20 yr). Similarly, the incidence of PTx increased from 3.3 per 1000 patient-years in patients who had been on RRT for <5 yr to 30 per 1000 patient-years in those receiving RRT for >10 yr. The Cox regression models showed that the relative risk for PTx was significantly higher in women and lower in elderly and diabetic patients. The relative risk for PTx (adjusted for gender, age, and nephropathy) was higher in the patients on peritoneal dialysis than in those on hemodialysis and decreased after transplantation. During the course of a follow-up of 7 yr, the incidence of PTx in patients who started RRT between 1990 and 1992 was no different from that observed in patients who started RRT between 1983 and 1985. In conclusion, the prevalence and incidence of PTx in patients receiving RRT in Lombardy is lower than that in Europe and Italy as a whole, as reported by the 1988 European Dialysis and Transplantation Association Registry; its frequency has not changed significantly during the past few years. The need for PTx decreases markedly after successful transplantation. The epidemiologic finding that the rate of PTx is greater in women, young patients, and individuals who do not have diabetes suggests the need for a more aggressive medical treatment of secondary hyperparathyroidism particularly in such patients.     

Etiology and epidemiology of end-stage renal disease in Dutch children 1987–2001

In this retrospective study 351 children (<16.0 years) with end-stage renal disease (ESRD) accepted for renal replacement therapy (RRT) in the four Dutch pediatric centers were analyzed for the period 1987–2001. The data were compared with a previous study performed in 1979–1986. Eighty patients were of non-Dutch origin. An annual ESRD incidence of 5.8 patients per million of the child population (p.m.c.p.) was calculated, without significant changes with time. The final prevalence in Dutch children under 15 years of ESRD was 38.7 p.m.c.p. The most frequent primary renal disease leading to ESRD was urethral valves, with a significant increase vs. the previous observation period (14% vs. 6%). The distribution of primary renal diseases was similar in patients of non-Dutch origin and in Dutch patients. Peritoneal dialysis was the most frequent dialysis procedure initially applied (62% vs. 26% in the earlier observation period). Thirteen percent of all first transplantations (n=278) were pre-emptive and 19% from living donors. Five-year graft survival after a living-donor and a cadaver graft was 80% and 73%, respectively. Overall patient survival after 10 years on RRT was 94%.     

Renal replacement therapy in the Canary Islands: demographic and survival analysis

BACKGROUND: The continuous increase in the number of patients on renal replacement therapy (RRT) has heightened the importance of renal patient registries to respond to the demand for data on the state of health, quality and cost of care provided for these patients. Our aim was to analyze the epidemiological profile of this population in the Canary Islands. METHODS: All patients on RRT between January 1999 and December 2003 were considered in this analysis. The information was obtained from the database of the Canary Registry of Renal Patients. RESULTS: We observed a continuous increase in incidence throughout the study period (from 138 per million population (pmp) in 1999 to 160 pmp in 2003), being more evident in patients >65 yrs. Prevalence followed a similar course, increasing from 875 to 972 pmp, being especially evident in the 65-74 yr age group. An alarming finding was the high incidence (43.5%) and prevalence (37.5%) of diabetic nephropathy. While the proportion of hemodialysis (HD) or transplant patients increased, that of peritoneal dialysis (PD) remained low and stable (prevalence of 5% in 2003). Almost half the RRT patients had functioning grafts, with a notably high rate of 58 transplants pmp in 2003, and a prevalence of 425 pmp. Age (hazard ratio (HR) [95% confidence interval (95% CI)] 1.04 [1.03-1.05]; p < 0.001) and diabetic nephropathy (1.47 [1.19-1.82]; p < 0.001) were independently associated with mortality in dialysis patients. Those returning to dialysis after graft loss had a 69% greater risk of death than incident dialysis patients (1.69 [1.06-2.69]; p = 0.026). Cardiovascular events were the main cause of death in all dialysis modalities. Patient death was the main cause of graft loss. CONCLUSIONS: The most outstanding finding was the high incidence and prevalence of patients on RRT, mainly due to diabetic nephropathy. Renal transplant rates were among the highest reported in renal patient registries.     

End-stage renal disease in North Africa

There are many similarities in the profile of chronic renal disease in the five North African countries, reflecting their close resemblance in ethnic background, bioecology and socioeconomic standards. The incidence of renal disease is much higher than that in the West, yet the prevalence is relatively lower, which mirrors the inadequacy of medical care facilities. The principal causes of end-stage chronic renal disease (ESRD) are interstitial nephritis (14 to 32%), often attributed to environmental pollution and inadvertent use of medications; glomerulonephritis (11 to 24%), mostly mesangioproliferative and focal segmental sclerosis; diabetes (5 to 20%) and nephrosclerosis (5 to 21%). Obstructive/reflux nephropathy, attributed to urinary schistosomiasis, is common in Egypt (7%), Libya and Southern Algeria. Primary urolithiasis is a frequent cause of obstructive nephropathy in the western (hyperoxaluria) and middle (cystinuria) regions. The incidence of tuberculosis is increasing, particularly the diffuse interstitial and hematogenous forms. It is responsible also for 10 to 40% of renal amyloidosis. The latter is also frequently associated with familial Mediterranean fever. Sickle cell anemia is an important health problem in the west, leading to a wide range of glomerular and tubulointerstitial nephropathies. Takayasu disease is increasingly recognized as a cause of ischemic nephropathy and renovascular hypertension. The management of ESRD is largely influenced by late referral, co-morbidities and lack of dialysis facilities. Hemodialysis is the most frequent modality of renal replacement therapy (RRT). CAPD is used sporadically. Renal transplantation, largely from live (often unrelated) donors, is offered to less than 5% of patients with ESRD. The reported outcome of RRT generally conforms with international standards.     

Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64)

BACKGROUND: The progression of nephropathy from diagnosis of type 2 diabetes has not been well described from a single population. This study sought to describe the development and progression through the stages of microalbuminuria, macroalbuminuria, persistently elevated plasma creatinine or renal replacement therapy (RRT), and death. METHODS: Using observed and modeled data from 5097 subjects in the UK Prospective Diabetes Study, we measured the annual probability of transition from stage to stage (incidence), prevalence, cumulative incidence, ten-year survival, median duration per stage, and risk of death from all-causes or cardiovascular disease. RESULTS: From diagnosis of diabetes, progression to microalbuminuria occurred at 2.0% per year, from microalbuminuria to macroalbuminuria at 2.8% per year, and from macroalbuminuria to elevated plasma creatinine (>or=175 micromol/L) or renal replacement therapy at 2.3% per year. Ten years following diagnosis of diabetes, the prevalence of microalbuminuria was 24.9%, of macroalbuminuria was 5.3%, and of elevated plasma creatinine or RRT was 0.8%. Patients with elevated plasma creatinine or RRT had an annual death rate of 19.2% (95% confidence interval, CI, 14.0 to 24.4%). There was a trend for increasing risk of cardiovascular death with increasing nephropathy (P < 0.0001), with an annual rate of 0.7% for subjects in the stage of no nephropathy, 2.0% for those with microalbuminuria, 3.5% for those with macroalbuminuria, and 12.1% with elevated plasma creatinine or RRT. Individuals with macroalbuminuria were more likely to die in any year than to develop renal failure. CONCLUSIONS: The proportion of patients with type 2 diabetes who develop microalbuminuria is substantial with one quarter affected by 10 years from diagnosis. Relatively fewer patients develop macroalbuminuria, but in those who do, the death rate exceeds the rate of progression to worse nephropathy.     

Cost-effectiveness of losartan in diabetic nephropathy: a Greek perspective

BACKGROUND: Diabetic nephropathy is the primary cause of end-stage renal disease (ESRD), which involves substantial economic burden. The primary objective of this study was to estimate the potential effect of losartan on the costs associated with ESRD in patients with diabetic nephropathy in a Greek setting. A secondary aim was to approximate the direct health care cost of renal replacement therapy (RRT) in Greece. METHODS: A cost-effectiveness analysis was performed to compare losartan with placebo in patients with type 2 diabetes and nephropathy. Clinical data were derived from the RENAAL study. All costs were calculated from the perspective of the Greek social insurance system, in 2003 euros. Future costs were discounted at 3%. The time horizon was 3.5 years. Extensive sensitivity analyses were performed. RESULTS: The reduction in the number of ESRD days over 3.5 years in patients treated with losartan reduced ESRD-related costs by 3,056.54 euros, resulting in net cost savings of 1,665.43 euros per patient. Net cost savings increase thereafter, increasing to 2,686.48 euros per patient over a period of 4.0 years. The results were robust under a wide range of plausible assumptions. The weighted mean daily cost of RRT was estimated at 90.97 euros per patient. The total economic burden of RRT for the year 2003 has been estimated at 304.773 million euros. CONCLUSIONS: This study demonstrated that treatment of patients with diabetic nephropathy in Greece with losartan is cost-effective, as it leads to important savings for the social insurance system by slowing the progression to ESRD.     

End-stage renal failure due to analgesic nephropathy, its changing pattern and cardiovascular mortality

The changing pattern of prevalence and age distribution of analgesicnephropathy as a cause of end-stage renal failure (ESRF) inpatients on RRT was analysed using the EDTA-ERA Registry's files.Comparing 1990 to 1981, the percentage of patients with analgesicnephropathy decreased in many European countries and the Registry'saverage came down from 3 to 2%. The highest prevalence was notedfor Switzerland, which showed a decrease from 28 in 1981 to12% in 1990. During the same interval the age distribution shiftedto the right with an increase in median age from 57 to 63 atstart of RRT for analgesic nephropathy. In Switzerland the age-specificacceptance rate to RRT for patients with analgesic nephropathydecreased to less than 1/3 in the age cohorts below 55 but increasedin those aged 65 or older. This increase in the elderly cohortsappeared to be related to the growing acceptance rate to RRTof elderly patients in general rather than to an increasingincidence of ESRF due to analgesic nephropathy. Mortality ingeneral and death rates due to cardiovascular causes were foundnot to differ in RRT patients with analgesic nephropathy fromthat of other standard primary renal diseases (excluding diabeticnephropathy and systemic diseases). Some 20 years after withdrawalof phenacetin from the analgesic market, analgesic nephropathyall but disappeared as a cause of ESRF in Sweden and Denmark,and the same may be expected to occur in countries like Switzerland,Belgium, and others in the not too far distant future.     

Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease

Background

Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited.

Methods

Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada’s universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4–9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation.

Results

Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0–3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0–3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period.

Conclusion

Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant.     

End-stage renal disease in Scotland: outcomes and standards of care

BACKGROUND: The number of patients starting renal replacement therapy (RRT) for end-stage renal disease (ESRD) in the United Kingdom rises annually. Patients are increasingly elderly with a greater prevalence of comorbid illness. Unadjusted survival, from the time of starting RRT, is not improving. The United Kingdom Renal Association has published recommended standards of treatment, which all United Kingdom nephrologists strive to attain. This study was devised to define the impact of attaining recommended treatment standards, adjusting for patient age and comorbid illnesses, upon survival on RRT in the United Kingdom population. METHODS: A prospective, registry based, observational study of all patients starting RRT in Scotland over a 1-year period, followed for the first 2 years of RRT. RESULTS: Of the 523 patients who were studied, 217 (41.5%) had died by 2 years of follow-up, 32% excluding deaths within the first 90 days. Age, comorbidity, weight when starting RRT, and attaining the recommended standards for albumin and hemoglobin had a significant impact upon survival. CONCLUSION: This study has emphasized the very high mortality of patients starting RRT in Scotland. By paying close attention to the attainment of recommended standards of care for patients with ESRD, it may be possible to improve upon current mortality figures. The monitoring of such success is only possible if correction is made for age and comorbidity.     

Diabetic nephropathy and end-stage renal failure: the Norwegian story

Diabetic nephropathy is the most common single cause of end-stage renal failure (ESRF) in the Western world, recorded as the cause of renal failure in up to 40% to 45% of those entering renal replacement therapy (RRT) programs. However, marked differences exist between countries; the percentage of patients entering RRT in Norway because of diabetic nephropathy is 10% of the incident RRT population. The percentage in the United States is approximately 40%; therefore, the purpose of the present study was to compare data from Norway with data from the United States in an attempt to detect factors that might explain some of the differences. To make the comparisons as valid as possible, an attempt has been made to focus on populations of similar genetic make-up. The incidence of type 1 diabetes is a little higher in Norway than in the United States, whereas the prevalence of type 2 diabetes may be twice as high in the United States as in Norway; marked differences in the prevalence of obesity is probably a significant causative factor. There seems to be no striking difference in the prevalence of microalbuminuria in people with diabetes in the two populations, whereas there are insufficient data to compare the prevalence of overt proteinuria. The incidence of patients with a diagnosis of diabetic nephropathy as the cause of ESRF entering RRT in the two study populations showed marked differences; the incidence for 1997 was 8.9/million population in Norway and 113/million population in the United States. The proportion of type 2 diabetes was 46% in Norway and 64% in the US (1997). It is unlikely that the marked difference in incidence of RRT can be explained by differences in type 2 diabetes prevalence alone. The populations may not be directly comparable, and differences in the size of study populations and in the choice of renal diagnosis in patients with diabetes as a comorbid factor at the beginning of RRT may introduce uncertainties. Further, data on other factors--such as incidence of death before RRT is indicated, quality of care, and health care delivery, expressed as degree of blood pressure and metabolic control--were not available. Differences in acceptance of diabetes patients into RRT programs are not believed to contribute significantly. Norway is seeing a development toward increasing body weight and a change toward a more sedentary lifestyle, together with an increasing prevalence of type 2 diabetes earlier in life than has previously been the case. An increase in diabetic nephropathy and need for RRT because of type 2 diabetes must therefore be expected in Norway. To understand differences and to best design preventive programs, further comparative studies of the two populations seem warranted.     

Overview: end-stage renal disease in the developing world

Although the vast majority of patients with end-stage renal disease (ESRD) worldwide live in what is called the developing world, little is known about its epidemiology and management. With the current paucity of credible and adequately representative registries, it is justified to resort to innovative means of obtaining information. In this attempt, world-renowned leading nephrologists in 10 developing countries collaborated in filling a 103-item questionnaire addressing epidemiology, etiology, and management of ESRD in their respective countries on the basis of integrating available data from different sources. Through this joint effort, it was possible to identify a number of important trends. These include the expected high prevalence of ESRD, despite the limited access to renal replacement therapy, and the dependence of prevalence on wealth. Glomerulonephritis, rather than diabetes, remains as the main cause of ESRD with significant geographical variations in the prevailing histopathological types. The implementation of different modalities of renal replacement therapy (RRT) is inhibited by the lack of funding, although governments, insurance companies, and donations usually constitute the major sponsors. Hemodialysis is the preferred modality in most countries with the exception of Mexico where chronic ambulatory peritoneal dialysis (CAPD) takes the lead. In several other countries, dialysis is available only for those on the transplant waiting list. Dialysis is associated with a high frequency of complications particularly HBV and HCV infections. Data on HIV are lacking. Aluminum intoxication remains as a major problem in a number of countries. Treatment withdrawal is common for socioeconomic reasons. Transplantation is offered to an average of 4 per million population (pmp). Recipient exclusion criteria are minimal. Donor selection criteria are generally loose regarding tissue typing, remote viral infection, and, in some countries, blood-relation to the recipient in live-donor transplants. Cadaver donors are accepted in many countries participating in this survey. Treatment outcomes with different RRT modalities are, on the average, inferior to the internationally acknowledged standards largely due to infective and cardiovascular complications.     

Ten-years trends in renal replacement therapy for end-stage renal disease in mainland France: Lessons from the French Renal Epidemiology and Information Network (REIN) registry

BackgroundThe incidence rate of renal replacement therapy (RRT) for end-stage renal disease (ESRD) is decreasing in several countries, but not in France. We studied the RRT trends in mainland France from 2005 to 2014 to understand the reasons for this discrepancy and determine the effects of ESRD management changes.MethodsData were extracted from the French Renal Epidemiology and Information Network registry. Time trends of RRT incidence and prevalence rates, patients’ clinical and treatment characteristics were analysed using the Joinpoint regression program and annual percentage changes. Survival within the first year of RRT was analysed using Kaplan-Meier estimates for 4 periods of time.ResultsThe overall age- and gender-adjusted RRT incidence rate increased from 144 to 159 individuals per million inhabitants (pmi) (+0.8% per year; 95% CI: 0.5–1.2) and the prevalence from 903 to 1141 pmi (+2.4% per year; 95% CI: 2.2–2.7). This increase concerned exclusively ESRD associated with type 2 diabetes (+4.0%; 3.4–4.6) and mostly elderly men. Despite patient aging and increasing comorbidity burden and a persistent 30% rate of emergency dialysis start, the one-year survival rate slightly improved from 82.1% (81.4–82.8) to 83.8% (83.3–84.4). Pre-emptive wait listing for renal transplantation and the percentage of wait-listed patients within one year after dialysis start strongly increased (from 5.6% to 15.5% and from 29% to 39%, respectively).ConclusionKidney transplantation and survival significantly improved despite the heavier patient burden. However, the rise in type 2 diabetes-related ESRD and the stable high rate of emergency dialysis start remain major issues.